Rhytidectomy

1. Rhytidectomy Marc Cohen, M.D. David Geffen School of Medicine at UCLA Division of Head & Neck Surgery

2. The Aging Face • Soft tissue changes • Skin changes

3. Soft Tissue Changes • Jowl • Deepened nasolabial folds and perioral jowling • Platysmal banding and submental fullness • Orbicularis oculi and malar fat pad ptosis

4. Skin Changes • Epidermis and subcutaneous fat thins • Flattening of dermal-epidermal junction • Elastosis: progressive loss of organization of elastic fibers and collagen • Photodamaged skin – striking variability

5. SMAS • Superficial Musculoaponeurotic System • 1976 Mitz and Pyronie Landmark paper • Fibromuscular fascial extension of the platysmal muscle that arises superiorly from the fascia over the zygomatic arch and is continuous in the inferior cheek with the platysma • Functions to transmit the activity of facial mimetic muscles to the facial skin

6. SMAS • Posteriorly, the SMAS fuses with the fascia overlying the sternocleidomastoid muscle, but it is a distinct layer superficial to the parotid fascia • Anterosuperiorly, the SMAS invests the facial mimetic muscles of the mid-face (i.e., orbicularis oculi, zygomatic major/minor, levator labii superioris) • Anteriorly, the SMAS invests the superficial portions of the orbicularis oris and gives off fibrous septae that insert into the dermis along the melolabial crease and upper lip

8. Facial Nerve • Protected by parotid tissue and lower branches are deep to masseter fascia • Potential space exists between SMAS and masseter fascia in inferior cheek • Important in deep/composite rhytidectomy techniques • Innvervates midfacial mimetic muscles from undersurface

9. Facial Nerve • Temporal branch is most superficial • Crosses junction of anterior 1/3 and posterior 2/3 of zygomatic arch • Above the arch it travels in the temporoparietal fascia to innervate frontalis and orbicularis oculi

10. SMAS & The Facial Nerve

11. Facelifts • Subperiosteal facelift

14. Subperiosteal facelift • Shortcomings • Frontal branch at higher risk • Significant facial edema lasting up to 6 weeks

15. Deep plane facelift • Addresses nasolabial folds • Subcutaneous • 2-3 cm in front of tragus • Sub-SMAS • To zygomaticus major • Superficial to zygomaticus major • Upper extent is malar eminence • Inferior extent is jawline

16. Deep plane facelift

17. Composite facelift • Addresses malar eminence • Lower blepharoplasty incision used to elevate orbicularis oculi and malar fat pad • Transition then made superficial to zygomaticus major

19. Nasolabial Fold

20. Nasolabial Fold • Boundary between cheek and upper lip • Laterally, thick subcutaneous layer • Medially, dermis almost approaches orbicularis • Cheek fat sags over time lateral to fold

21. Upper third – insertion into LLSAN muscle • Middle third – transition btw both muscles • Lower third – insertion into OO • Deep plane and periosteal lifts do not anatomically address this • Controversial – SMAS or not

22. Nasolabial Fold Management • Direct excision (UCLA) • ePTFE (gortex) • Fillers • SMAS • Facelifts? Midface lifts? • Botox (LLSAN)

23. Botox

24. Direct Excision

25. Lift and Peel at same time? • Concern for flap necrosis • Retrospective studies show no increased incidence of flap necrosis or other complications

26. Retaining Ligaments of the Face • Osteocutaneous • Orbital – centered at zygomaticofrontal suture • Zygomatic • Buccal-maxillary – arises from zygomaticomaxillary suture • Mandibular (along with DAO makes up labiomandibular crease) • Fasciocutaneous • Masseteric (anterior border of masseter • Parotidocutaneous

28. Blood Supply • ECA • STA • Transverse facial artery • Zygomaticorbital artery • Facial • Submental • Inferior labial • Superior labial • Angular

29. Blood Supply

30. Complications - Hematoma • HTN is major risk factor (2.6x risk) • Major – usually occur in first 12 hours • reoperation and exploration • Minor – occur during the first week • Evacuated with 18 ga needle or small opening in incision line, pressure dressing, abx

31. Complications – Flap necrosis • Postauricular is most common site • Preauricular is 2nd most common • Deep-plane facelifts have a decreased incidence of necrosis • Nicotine carries a 12.6x risk for flap necrosis • Must stop at least 2 weeks prior • Treat conservatively with with daily peroxide cleaning, limited debridement, and topical abx ointment • Most heal nicely

32. Complications – Nerve Damage • Most commonly injured nerve is great auricular • If injured, should be repaired with 9-0 nylon • Temporal and Marginal are the most commonly injured motor nerves • Studies differ on which is more commonly injured (which technique, etc.) • Treatment • First 4-8 hours, wait • If prolonged, do NOT re-explore • 85% will resolve with time • Reconstruct after 1 year • Patients with a hx of Bell’s palsy are at risk for recurrence after rhytidectomy

33. Complications • Hypertrophic scarring • Occurs with excessive tension on flap closure • More commonly with isolated subcutaneous flap dissections • Treat with steroids • Defer excision and primary closure until at least 6 months postoperatively • Alopecia • Wait 3-6 months, then excise or place grafts

34. Complications • Infection • Common pathogens are staph and strep • Usually respond to oral abx • Rare for abscess to form • Earlobe deformity (pixie ear) • V-Y plasty performed 6 months after surgery

36. Complications • Parotid injury • Sialocele or fistula • Needle aspiration and pressure dressings